Welcome to Hunter Specialty Anaesthesia

Book a Consult with Dr Rothwell

Welcome to Hunter Specialty Anaesthesia

Book a Consult with Dr Rothwell

Welcome to Hunter Specialty Anaesthesia

Book a Consult with Dr Rothwell

patient form

On April 3rd 2017 by admin

patient form

YOUR DETAILS

Patient’s Name

DOB

Gender

MaleFemale

Are you the patient?

YesNo

If ‘No’, please provide your name and relationship to the patient

Address

Your Email

Your Phone Number

Name of Patient’s Health Fund

Height (cm)

Weight (kg)

Operation Details:

Surgeon

If ‘other’ please specify

Hospital

If ‘other’ please specify

Name of Operation/Procedure

Date of Operation/Procedure

Details about you and your health

Have you had any problems with anaesthetics in the past?

YesNo

If ‘Other’ please specify

Do you have any Allergies?
(this includes all tablets, puffers, patches, sprays, injections, eye drops, etc.)

YesNo

If ‘Other’ please specify

Do you take any regular medications?
(Including ALL prescription, ‘over the counter’, vitamins and herbal preparations)

YesNo

If ‘Other’ please specify

Do you take any blood thinners?
(including fish oil, krill oil or any derivatives or similar preparations)

YesNo

If ‘Other’ please specify

Do you smoke?

YesNo

If ‘Other’ please specify

Do you drink alcohol?

YesNo

If ‘Yes’ please specify how many standard drinks per day

Have you used any ‘recreational’ drugs or have in the last few weeks?
Have you used any ‘recreational’ drugs or have in the last few weeks?
(This information is confidential and only required as some drugs can have serious interactions and consequences when having an anaesthetic)

YesNorather not say

Do you have, or have you ever had, any of the following?

Any trouble with your heart or cardiovascular system?
(this could include high blood pressure, chest pains, angina, heart attacks, coronary artery stents, coronary artery bypass surgery, heart rhythm problems, having a pacemaker or defibrillator, strokes or mini strokes)

YesNo

If ‘Other’ please specify

Any trouble with your lungs or respiratory system?
(this could include asthma, obstructive sleep apnoea (OSA) with or without CPAP mask use, or smoking-
related problems)

YesNo

If ‘Other’ please specify

Diabetes?

YesNo

If ‘Other’ please specify

Gastro-oesophageal reflux disease (GORD), gastritis, oesophagitis, stomach or duodenal ulcers, hiatus hernia?

YesNo

If ‘Other’ please specify

Thyroid or any other endocrine disease?

YesNo

If ‘Other’ please specify

Kidney condition?

YesNo

If ‘Other’ please specify

Any neurological diseases/disorders
(including stroke, epilepsy, tumours, MS, muscular disorders/dystrophy, fainting episodes, migraine, paralysis)

YesNo

If ‘Other’ please specify

Any Mental Health Issues
(including depression, anxiety, bipolar disorder, schizophrenia)

YesNo

If ‘Other’ please specify

Blood clots or excessive bleeding/bleeding disorders?
(eg. deep vein thrombosis (DVT), pulmonary embolism (PE), haemophilia, and others)

YesNo

If ‘Other’ please specify

With regards to your teeth or dentition – what do you have?
(please select all that apply)

Loose tooth or teethChipped tooth or teethCaps, crowns, or veneersImplant(s)Bridge(s)BracesTemporary crowns, etcPartial upper denturesPartial lower denturesFull upper denturesFull lower denturesYour own teeth +/- fillings only +/- retainer wire (from braces)

Upload medical information
(please feel free to upload any medical reports, test results, Specialist letters or supporting information)

Name and telephone numbers of your doctors (GPs and Specialists)

Do you give your consent for me to contact your other doctors if required?
(to provide you with the safest anaesthetic your anaesthetist may need to contact your other doctors to obtain test results, specialist letters, or other information. This allows better understanding of your health, meaning your anaesthetic can be individualised appropriately)

YesNo

Your anaesthetist will receive all the information submitted via this questionnaire. Depending upon your answers, your anaesthetist may decide to contact you to obtain more information, or simply to discuss particular aspects of the anaesthetic. Alternatively, your anaesthetist may be satisfied with the information submitted and be ready to proceed with your anaesthetic as is.

By submitting this form you confirm the information provided is true and correct to the best of your knowledge and can be relied upon by your anaesthetist in making clinical decisions.

Is there anything else you would like to mention?

YesNo

If ‘Other’, please specify

Send me a copy of this message (email only)

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